School Medication Administration Authorization Form

MARYLAND STATE SCHOOL MEDICATION ADMINISTRATION AUTHORIZATION FORM

This order is valid only for school year (current)                                            including the summer session.

This form must be completed fully in order for schools to administer the required medication. A new medication administration form must be completed at the beginning of each school year, for each medication, and each time there is a change in dosage or time of administration of a medication.

* Prescription medication must be in a container labeled by the pharmacist or prescriber.

* Non-prescription medication must be in the original container with the label intact.

* An adult must bring the medication to the school.

* The school nurse (RN) will call the prescriber, as allowed by HIPAA, if a question arises about the child and         /  or the child's medication.

PRESCRIBER'S AUTHORIZATION

Relevant side effects:

Use forPrescriber's Address Stamp/Signature

(Original Signature or Signature Stamp ONLY)

Prescriber's Signature:

PARENT/GUARDIAN AUTHORIZATION

I/We request designated school personnel to administer the medication as prescribed by the above prescriber. I/We certify that I/we have legal authority to consent to medical treatment for the student named above, including the administration of medication at school. I/We understand that at the end of the school year, an adult must pick up the medication, otherwise it will be discarded. I/We authorize the school nurse to communicate with the health care provider as allowed by HIPAA.

Parent/Guardian Signature

SELF CARRY/SELF ADMINISTRATION OF EMERGENCY MEDICATION AUTHORIZATION/APPROVAL

Self carry/self administration of emergency medication may be authorized by the prescriber and must be approved by the school nurse according to the State medication policy.

Prescriber's authorization for self carry/self administration of emergency medication (SIGNATURE):

School RN approval for self carry/self administration of emergency medication (SIGNATURE):

Order reviewed by the school RN (SIGNATURE):

Saint Martin's Lutheran School of Annapolis

Main Office: (410) 269-1955   |   Admissions: (410) 263-8016

1120 Spa Road Annapolis, MD 21403